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Malnutrition Identification & Documentation

of the Hospitalized Patient

Angela Lago MS RD LDN CNSC; Manager, Clinical Nutrition angela.lago@nhrmc.org

Linda Rhodes RN BSN CCDS; Manager, Clinical Documentation Improvement linda.rhodes@nhrmc.org

Introduction and Project Selection

▪ Increased focus on high-quality affordable care

necessitated the need to address the ongoing issue of

malnutrition in hospitalized patients.

▪ 30% of hospitalized patients are malnourished and 17%

are likely to readmit within 30 days.

▪ Malnourished patients are twice as likely to develop

pressure ulcers and have three times the risk for surgical

site infections. Almost half of all patients who fall are

malnourished.1

▪ The estimated annual income burden of disease-

associated malnutrition is 156.7 billion. 1

▪ With NHRMC’s mission statement of “Leading Our

Community to Outstanding Health”, having more defined

criteria for diagnosing and documenting malnutrition

allows the interdisciplinary care team to identify concrete,

objective characteristics when assessing patients for

malnutrition. By doing this in a more uniform and concise

fashion, our goal is the prevention of compromise to the

short and long-term nutritional status of our patients

Goals

Improvement Process

▪ Multidisciplinary team approach to identify improvement

process with malnutrition.

• Clinical Nutrition Manager

• 3 Registered Dietitians

• Director Food & Nutrition Services

• Clinical Documentation Improvement (CDI) Manager

• Clinical Documentation Improvement Specialist

• NHRMC Hospitalist Physician

• Coding Manager and Coordinator

▪ Clinical Nutrition Team

• Value Stream manager

• Developed the Nutrition Focused Physical Exam(NFPE)

flow sheets & Nutrition Navigator in the EMR(EPIC)

• Received webinar education and skills lab checkoff on

diagnosing malnutrition utilizing NFPE

• Provided education to CDI and Coding teams

% Acute Adult Inpatient Discharges

Nutrition Focused Physical Exam

▪ Clinical Documentation Improvement & Coding Team.

• Provided education to registered nurses, additional CDI

and coding staff, hospital providers

• Developed and shared malnutrition talking points for

nursing unit daily huddles

• Updated CDI and Coding Queries with ASPEN

malnutrition clinical indicators

• Developed and displayed Malnutrition education poster

for providers

Nursing & Provider Education

▪ Physician Champions:.

• Shared malnutrition initiative with provider teams

• Received ASPEN criteria Pocket Guide- distributed to all

providers

Results/Outcomes

Mortality Index Observed/Expected Acute Inpatient

Summary

This initiative has demonstrated that through development of

standardized definitions of malnutrition, focused education

and assessment of clinical staff, and a consistent approach

to nutrition screening, there has been a significant increase in

the number of nutrition consults and patients identified and

treated with the diagnosis of malnutrition. In addition,

increased reimbursement has been captured, along with

lowering of mortality index. This process has become

Standard Work at New Hanover Regional Medical Center.

Future expansion includes exploring a malnutrition initiative

in the pediatric population and exploring post discharge

opportunities to provide continued nourishment of identified

patients. Finally, we plan to evaluate how the malnutrition

program impacts readmission rates.

▪ Angela Lago MS, RD, LDN, CNSC / Manager,

Clinical Nutrition

▪ Linda Rhodes RN, BSN, CCDS / Manager,

Clinical Documentation Improvement

▪ Melanie Adams / Director Food and Nutrition

Services

▪ Tony Blue, MD / Medical Staff Advisor

▪ Natalie George, RHIA, CCS, CDIP/ Manager

Coding

▪ MeAnn Parker, CCS, CPC / Coordinator Coding

▪ Karen Holmes, RN, CCDS

▪ Connie Brenstuhl MS, RD, CSR

▪ Charlene Chan RD, LDN

▪ Kristin Denstedt RD, LDN, CNSC

To develop and implement a collaborative malnutrition initiative

for the inpatient population. To improve capture of malnutrition

diagnoses of inpatient discharges by 3% within 6 months.

TEAM

Objectives

▪ Develop a multidisciplinary team to problem solve

malnutrition issues utilizing the LEAN methodology.

▪ Adopt facility wide standard evidence based criteria for

definition of malnutrition. Adopting the evidence-based

malnutrition guidelines supported by The Academy of

Nutrition and Dietetics (AND) and the American Society

for Parental and Enteral Nutrition (ASPEN) to standardize

the criteria for adult malnutrition was an important step in

standardization and consistency.

▪ Educate clinical and coding staff on definitions of

malnutrition and documentation requirements.

▪ Educate dietitian staff on nutrition focused physical

assessments to identify malnutrition diagnoses.

▪ Improve provider documentation of malnutrition

diagnoses.

▪ Realize additional reimbursement due to documentation

of malnutrition diagnoses.

▪ Improve Mortality Index Observed/Expected due to

additional capture of malnutrition diagnoses. Malnutrition

diagnosis capture an increase in the patient’s severity of

illness and risk of mortality ratings.

5.74%

7.73% 7.78%

7.41%

6.65%

7.58%

8.29%

7.44% 7.55%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

July August September October November December January February March

% Malnutrition July 2016-March 2017

$0.00

$147,040.50

$137,398.50 $103,651.50

$38,568.00

$118,114.50

$173,556.00

$98,350.50

$151,861.50

0

50

100

150

200

250

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

July 2016 August 2016 September2016

October 2016 November2016

December2016

January 2017 February 2017 March 2017

Malnutrition w/Financial Impact

# Malnutrition Cases $$ impact over baseline 144 cases

(Figure 1)

(Figure 2)

Comparison of Clinical Nutrition Services Workload January 2016-172

Nutrition Consults January 2016 January 2017 Change

MD Consult 482 532 +50

RN Query 442 659 +217

System Generated 426 644 +218

TOTAL 1350 1835 +485

(Figure 3)

(Figure 4)

NOTES

1. The Joint Commission Journal on Quality and Patient Safety, October 2015,

Volume 41 Number 10, page 469-470

2. Data is specific to inpatient adult dietitians and does not include nutrition support

services (TPN), Rounding & other responsibilities carried out by the RD.